Saturday, December 27, 2014

The influx of for-profit companies into the hospice field has benefited patients, advocates say, because the commercial companies made big investments in technology, focused on efficiency and made care more accessible.

But a Washington Post analysis of hundreds of thousands of U.S. hospice records indicates that, as those companies transformed a movement once dominated by community and religious organizations into a $17 billion industry, patient care suffered along the way.

On several key measures, for-profit hospices as a group fall short of those run by nonprofit organizations.

The typical for-profit hospice:

●Spends less on nursing per patient.

●Is less likely to have sent a nurse to a patient's home in the last days of life.

●Is less likely to provide more intense levels of care for patients undergoing a crisis in their symptoms.

●Has a higher percentage of patients who drop out of hospice care before dying. High rates of dropout are often viewed as a sign that patients were pushed out of hospice when their care grew expensive, left dissatisfied or were enrolled for hospice even though they were not close to death.

Thursday, December 25, 2014

LONDON – When British Prime Minister David Cameron asked me in July to lead an effort to find solutions to the growing global problem of antimicrobial resistance, my first question was: "What is that?" I soon learned that, as bacteria and parasites develop resistance to existing drugs, like antibiotics and antimalarial medications, the world is at risk of losing its battle against infectious diseases. So my next question was: "Why me? Don't you need a scientist?"

It turns out that the problem of rising antimicrobial resistance is as much about economics as it is about science or medicine. Left unchecked, it will kill millions of people every year, and have serious adverse economic consequences for the world. For developing economies, including most of the BRIC (Brazil, Russia, India, and China) and MINT (Mexico, Indonesia, Nigeria, and Turkey) countries, the risk is particularly large.

Recent research, by an independent review on antimicrobial resistance, which I chair, has modeled the phenomenon's likely impact on the world economy. It suggests that if we fail to address antimicrobial resistance, the problem will grow worse.

By 2020, if we allow resistance to rise by 40%, global GDP will be 0.5% smaller than it otherwise would have been. By 2030, it will be 1.4% smaller. By 2050, the economic shortfall will reach 3%. The accumulated loss of global output over the next 35 years will total $100 trillion – more than one and a half times annual world GDP today.

Already, 60,000 people die every year from causes related to antimicrobial resistance in the United States and Europe – some ten times the worldwide death toll from the ongoing Ebola crisis. By 2050, if the problem is allowed to continue to grow, antimicrobial resistance will kill more than ten million people per year. That is more than the number of people who currently die of cancer, and greater than the number of deaths from diabetes, lung cancer, road traffic accidents, diarrhoeal disease, and HIV combined. The economic costs from the resulting panic, including a collapse of travel and trade, could be devastating.

Rising rates of antimicrobial resistance will have a particularly severe impact on India, Indonesia, and Nigeria (as well as the rest of Sub-Saharan Africa). Countries like China and Brazil, which have been successful in reducing malaria rates, could see their hard work undermined by an increase in resistance to antimalarial drugs.

The research we commissioned was based on the limited data available. It does not take into account the damage from drug-resistant illnesses outside of hospitals or the impact of escalating healthcare costs. Nor does it include the drop in living standards from the loss of life-enhancing treatments – for example, knee or hip replacements, cancer treatment, and caesarean sections – that rely on antibiotics to prevent infections. The broad-brush research we conducted shows that such treatments – many of which would not be possible without effective antibiotics – add around 4% of benefit in terms of GDP.

One of my goals is to persuade policymakers at the United Nations to agree to a set of rules and policies to stop the growth of antimicrobial resistance. In addition to highlighting the scale of the problem, the review is seeking to find ways to reduce drug resistance and to stimulate the production of new antibiotics to compensate for the loss of those that are now or will become ineffective.

Some solutions to reduce resistance will require cutting-edge technology. We must encourage policymakers to support the development of the best diagnostics. Quicker, more accurate diagnoses will curb the current overreliance on antibiotics – a key requirement for combating resistance. We also must develop tools to identify and halt outbreaks of resistant diseases at an early stage. Data provided by diagnostic devices could be a potent weapon in containing these outbreaks.

Other solutions are low tech, requiring little more than common sense. We need to start washing our hands thoroughly and often. We need to stop demanding antibiotics from our doctors. And, when antibiotics are called for, we need to finish the prescribed course. As we try to prevent resistance to existing drugs, we will also need to examine the impact of antibiotics in agriculture.

Developing new antibiotics is a challenge, because pharmaceutical companies seem to need incentives to conduct the required research. The review will study whether market incentives can be changed. If they cannot, more dramatic alternatives to boost early innovation by university labs and small companies could be sought, perhaps through a targeted fund.

Monday, December 22, 2014

The patient was gravely ill, but a lengthy note by nurses at a Halifax hospital focused on the person's next of kin. The relative, they complained, was making trouble, demanding aggressive treatment that seemed inappropriate — a source of frequent tension in Canadian health care.

Tuesday, December 16, 2014

The doctor floated through the intensive care unit, white lab coat flapping, moving from room to room, scanning one chart and then another, often frowning.

Unlike TV dramas, where the victims of car crashes and gun shots populate the ICU, this one at Sentara Norfolk General, as in others in the United States, is more often filled with the wreckage of chronic disease and old age.

IT'S hard to believe that another 10 years have passed, but the proof is the 11-volume stack of medical review books at my bedside. It's time for the decennial rite of cramming a thousand pages of facts for an eight-hour-long multiple choice test.

Doctors are licensed by their states to practice medicine, but they're also expected to be "board-certified" in their particular field — surgery, obstetrics, pediatrics, etc. This certification comes from the professional organization of each field. In my case, it's the American Board of Internal Medicine.

It used to be that you tackled those monstrous board exams just once after residency. Then you went into practice and never looked at a No. 2 pencil again. But in 1990, the boards decided that doctors should recertify every 10 years. This seemed reasonable, given how much medicine changes. Over time, though, the recertification process has become its own industry. The exam has been supplemented with a growing number of maintenance-of-certification, or M.O.C., requirements. Some are knowledge-based exercises, but many are "practice assessments" meant to improve care in your own practice that end up being just onerous paperwork. And the recertification process and associated materials cost doctors thousands of dollars.

PRINCETON, N.J. — Len Charlap, a retired math professor, has had two outpatient echocardiograms in the past three years that scanned the valves of his heart. The first, performed by a technician at a community hospital near his home here in central New Jersey, lasted less than 30 minutes. The next, at a premier academic medical center in Boston, took three times as long and involved a cardiologist.

And yet, when he saw the charges, the numbers seemed backward: The community hospital had charged about $5,500, while the Harvard teaching hospital had billed $1,400 for the much more elaborate test. "Why would that be?" Mr. Charlap asked. "It really bothered me."

In the aftermath of what we shrinks call "August" — a euphemism for the acute clinical moments that our patients experience while we're away for the standard three to five weeks of vacation — I found myself reflecting on a series of physical accidents that befell too many of my patients during my break not to note.

If two patients fall down stairs, another is involved in a pedestrian accident, one more falls off her bike and yet another suffers severe burns, what am I to make of this? Was it coincidence? Or were their mishaps somehow a continuation of their work with me in analysis?

Thursday, December 4, 2014

AMRAVATI, India — A deadly epidemic that could have global implications is quietly sweeping India, and among its many victims are tens of thousands of newborns dying because once-miraculous cures no longer work.

These infants are born with bacterial infections that are resistant to most known antibiotics, and more than 58,000 died last year as a result, a recent study found. While that is still a fraction of the nearly 800,000 newborns who die annually in India, Indian pediatricians say that the rising toll of resistant infections could soon swamp efforts to improve India's abysmal infant death rate. Nearly a third of the world's newborn deaths occur in India.

"Reducing newborn deaths in India is one of the most important public health priorities in the world, and this will require treating an increasing number of neonates who have sepsis and pneumonia," said Dr. Vinod Paul, chief of pediatrics at the All India Institute of Medical Sciences and the leader of the study. "But if resistant infections keep growing, that progress could slow, stop or even reverse itself. And that would be a disaster for not only India but the entire world."

Chronic diseases like cancer and heart disease are rising fast in low- and middle-income countries, striking far younger populations than in rich countries and causing much worse outcomes, according to a new report.

Deaths from chronic diseases have risen by more than 50 percent in low- and middle-income countries over the past two decades, according to the report, by the Council on Foreign Relations. The increase is part of a shift in global mortality patterns in which infectious diseases, such as malaria and tuberculosis, have declined substantially and are no longer the leading cause of death in the developing world.

The shift in poorer countries is being driven by urbanization and other major changes that have led to improvements in aspects of public health, such as hand washing, sanitation and vaccines. That has led to sharp declines in infant mortality, and in turn, to increases in life spans. The average life expectancy in Africa, for example, has increased by about eight years since 2000, according to the World Health Organization.

Tuesday, December 2, 2014

I'm a primary care physician, but with my young adult patients, I'm secretly a therapist, too.

When a new patient between the ages of 18 and 25 arrives at my office, he or she generally has a specific request: a physical exam as clearance for football season, a refill of an asthma inhaler, reassurance that a sore throat isn't strep. These young men and women are healthy and don't expect to be asked very much, or little beyond the usual waiting room questionnaire.

My job, as I see it, is not only to respond to any requests or questions, but also to ask them about the things 18- to 25-year-olds do: attend college (or consider it), search for employment, separate from (or return to live with) parents, find romantic partners, shrug off one-night stands, run out of money, feel confused or depressed or anxious, experiment with drugs and alcohol.

The last topic is of special concern for me. I've seen too many people get sidetracked by drugs; I don't want to miss any signs.

Early in my career, I wasn't planning to act as a therapist — I was trained mostly to listen to hearts and lungs and feel for lymph nodes — but once I started seeing young adults I discovered the unspoken problems and hidden distress I should be looking for. Not that these young patients think of encounters with me as psychotherapy, God forbid; we're just talking.

In my experience, most young adults rarely, if ever, have a personal, 30-minute conversation with an adult. They talk mostly to people their own age. To my patients I'm a curious stranger with whom they're stuck for a while in a small room. Fortunately, most of them like talking about themselves, about their decisions and doubts. They know that after half an hour we will part company, that what they've told me goes no further. If I do my job well, they might just stumble into telling their story.

Lidia, 22, and soon to graduate college, comes in wearing jeans and a T-shirt that reads OBEY. Some minutes after we've discussed the reason for this appointment — eczema — I say: "I'm interested in how you would compare yourself today to your 18-year-old self. Do you feel like you're moving along into adulthood?"

She looks surprised by my question. But to hear about Lidia's life, I need to be broadly interested and indirect. The question defuses the pressure of asking about private things and gets her talking.

"I'm better at handling problems than I was a few years ago," she says. "I don't depend on my parents for everything. In the old days, when I had trouble with a roommate, I might have called my parents and moved home. Now I just wait for the lease to end."

I want to hear a full self-portrait, so I ask, "What things are most important to you at the moment?"

"Getting a job, completing school, putting my parents' minds at ease, making my own happiness even if it feels hard at times or I don't know what will make me happy."

By bringing up "happiness," she has given me an opening to wander into the topic of drugs.

"Does marijuana or alcohol play a part in your happiness?" I ask.

"I don't drink much because I don't like feeling hung over, but I'm smoking more weed than I was last year. I'm flipping between if I should stop and if I'm just gonna have some fun. Back and forth."

Marijuana use peaks between the ages of 19 and 22. According to surveys, 15 to 20 percent of this age group has smoked in the past month. Yet these young adults often have exaggerated perceptions about their peers' use, estimating more than half the people their age smoke pot. Sometimes I set them straight about the norms, but with Lidia I withhold this information because I don't want to break the flow of our conversation.

Rather than ask about the specifics — the amount and her frequency of use — and put her on the spot, I ask, "It's hard to think about the next week, but where do you think you'd like your marijuana use to be in a year?"

Look back to when you were 18, I'm suggesting again, and now look forward.

"I don't want to stop completely because it would weird out my friends. But I could if I had to, like if my job was going to test me, or if I had to save money."

I listen carefully for the reasons Lidia gives, trying to hear if I should be worried that her marijuana use is problematic. I'm not overly troubled when she says, "I don't think marijuana affects me like it does a lot of people." She may underestimate the effects of marijuana or perhaps marijuana does not affect her negatively at all. What's key is that she doesn't mention that she smokes to forget her troubles, or because she's sad or nervous, phrases that would suggest there's a larger problem.

With David I worry. David, 19, short-haired and big-eared, a part-time community college student, informs me that he wants to be "a great decision-maker." He reports the pride of owning a new laptop, telling me "bills create discipline." But then, as if the word "discipline" reminds him of something, he says: "My mom is going back to jail. She didn't make the right decisions in the free world." He adds: "That makes me push toward drugs. It helps me deal with it."

David isn't sure how to deal with the stress he's under. "I want to be a man of stature, but there's pressure on my shoulders," he says. "I'm not sure how to cope with what I'm going through."

As with Lidia, there is no specific amount or frequency of marijuana use that is acceptable or unacceptable; there is no magic number I'm waiting for David to announce so that I can give him a label, and offer him counsel. But if someone is smoking daily and during daylight hours, I pay special attention, so when David tells me he smokes "either before or after noon," a red flag goes up.

Here's what I'm trying to differentiate: Is this person using marijuana for fun, because it's what friends do when they're together, or to mitigate negative feelings? Using marijuana "to cope" is often a marker for other pathology — serious mental health problems, anxiety, attention deficit disorder, concurrent alcohol abuse, major depression. That's what I'll want to hear more about next time with David.

Although I'm concerned about his drug use and his admission of distress, this first visit is an orientation, an introduction. I will ask him to come see me again, and soon. Sometimes a person like David will return for more primary care, interested in himself, worried about himself, intrigued by the idiosyncrasies of an adult conversation, and I will continue to evaluate him. Sometimes people like David never reappear, perhaps embarrassed by what they've admitted or upset by my prying.

Life often changes dramatically in a matter of months at their age, sometimes physically, but more often psychically. New pleasures come along, and also new risks, new forms of distress that are deep and real and need attention. But this is not likely to be revealed unless a young adult is encouraged to find his or her way to a primary care doctor, and unless that doctor accepts that this may be the one conversation with an adult for this patient this season, and tries to understand what's happening in the full life of a David or a Lidia, a young adult who may have arrived asking simply for a refill.

Some details have been altered to protect patient privacy.

Michael Stein, a professor of medicine and of health services, policy and practice at Brown University, is the author of "The Addict: One Patient, One Doctor, One Year" and "The Lonely Patient: How We Experience Illness."

Improved patient safety and fewer mistakes at U.S. hospitals saved the lives of roughly 50,000 people from 2011 to 2013, the Obama administration reported Tuesday.

Incidents of hospital-induced harm – such as adverse drug events, infections, falls and bedsores – fell by 17 percent, or an estimated 1.3 million episodes, from 2010.

The improvements, driven by a number of public and private initiatives, saved an estimated $12 billion in health care spending, according to a new government report that found dramatic progress in the fight to curb preventable medical injuries at U.S. hospitals.

Of the estimated 50,000 fewer deaths, a decline in bedsores, or pressure ulcers, helped save roughly 20,300 lives. A drop in adverse drug events – such as overdoses or administering the wrong medication – saved another 11,500 lives.

In a speech Tuesday in Baltimore, Health and Human Services Secretary Sylvia Mathews Burwell said the new HHS estimates represented "historic progress on health care quality."

"A 17 percent reduction in hospital-acquired conditions is a big deal, but it's only a start," Burwell said. "No American should ever lose his or her life, or spend the holidays in the hospital, because of a condition that could have been prevented."

Analysts from HHS looked at 18,000 to 33,000 medical records for each of the three years covered by the study. They estimate that nearly 10 percent of hospitalized patients in the U.S. experienced one or more of the numerous hospital-acquired conditions they were looking for.

"That rate is still too high," the report found.

Hospital-induced harm to patients has been a black cloud over the U.S. health care system for decades. The Centers for Disease Control and Prevention estimates that 2 million people each year suffer hospital-acquired infections, such as bloodstream and urinary tract infections from catheters.

In 2010, the government estimated that 27 percent of hospitalized Medicare patients sustained injuries associated with their care. Half of these patients had one or more episodes that either prolonged their hospital stays, caused permanent harm, required lifesaving interventions or resulted in death, HHS investigators found. About half the incidents were preventable.

Tuesday, November 25, 2014

'That's it — I'm done," Rachel Miller proclaimed, the sting of the neurologist's judgment fresh as she recounted the just-concluded appointment to her husband. Whatever was wrong with her, Miller decided after that 2009 encounter, she was not willing to risk additional humiliation by seeing another doctor who might dismiss her problems as psychosomatic.

The Baltimore marketing executive had spent the previous two years trying to figure out what was causing her bizarre symptoms, some of which she knew made her sound delusional. Her eyes felt "weird," although her vision was 20/20. Normal sounds seemed hugely amplified: at night when she lay in bed, her breathing and heartbeat were deafening. Water pounding on her back in the shower sounded like a roar. She was plagued by dizziness.

"I had started to feel like a person in one of those stories where someone has been committed to a mental hospital by mistake or malice and they desperately try to appear sane," recalled Miller, now 53. She began to wonder if she really was crazy; numerous tests had ruled out a host of possible causes, including a brain tumor. Continuing to look for answers seemed futile, since all the doctors she had seen had failed to come up with anything conclusive.

Trying to shop around for the best deal on health care services can be maddening. So Lisa Aliferis, a health care reporter for KQED News in San Francisco, came up with a simple idea: ask people what charges they're actually seeing on their bills and try to make sense of the madness.

We already know there's a huge variation in what hospitals charge for the most basic health-care services, based on their internal price listings. For instance, the average cost of a primary care visit ranges from $95 in Miami to $251 in San Francisco, according to a comprehensive study of employer-provided insurance coverage earlier this year. A first-of-its-kind data release from Medicare last year showed similar variations in the prices charged by hospitals.

But insurers and patients rarely pay the listed price. Aliferis — in a partnership with KPCC, a public radio station in Los Angeles, and Clearhealthcosts.com, a health transparency startup — tried to capture information of actual prices that people, who reported the information anonymously, were seeing on their medical bills — breaking down what the insurers were charged and what people actually paid.

Shefound big price differences within the same state, based on facility and insurance status. Private insurers in the Los Angeles and San Francisco areas paid anywhere between $128 and $694 for a mammogram, a procedure performed about 38 million times a year. A Medicare patient was charged $255 for a lower back MRI, while another uninsured patient was charged $6,221 at an academic medical center for the same procedure, Aliferis wrote.

Her database relies on reports for individuals and hasn't been without its problems. The most common complaints, Aliferis writes, is that it's still hard to comparison shop — it's not going to be easy as buying a retail item online. Also, the price of a health-care service doesn't say anything about the quality of that service. In health care, there's really no correlation between the two.

We rushed her, head wrapped like a tiny mummy, to the medical center at MIT, where we generally go for pediatric care. Julia wept while the nurse cleaned and examined her lacerated skin. After a short exam, she sent us to the emergency department at Children's Hospital Boston for stitches. "How bad is that, generally?" I asked, having never experienced suturing either for myself or my cautious, risk-averse, older daughter.

"It can be traumatic," the nurse said.

Julia cried, "I don't want stitches."

It's a large needle, but Julia is too busy coloring to notice.

So I braced myself for the worst: an endless wait and nerve-wracking bustle; screaming, germ-laden children and brusque, end-of-shift staff. But more than anything, I dreaded the inevitable pain in store for my small child with the deep cut.

(I know, kids get banged up on the path to adulthood and some pain is unavoidable. Still, when bloody heads are involved, I tend to overreact.)

Indeed, I was in full Mama Bear mode when into our exam room strode Dr. Baruch Krauss, the attending physician that evening.

Dark, lean and intense, Dr. Krauss shook my hand and then went straight to Julia, complimenting her pink, sparkly shoes. She lit up and was eager to chat. They talked about exactly how old she was (nearly six-and-three-quarters) and what she likes to do (climb trees). Then he gently rubbed a bit of Novocaine gel on her cut and said he'd be back.

Five times over the next 40 minutes or so, Krauss came in and re-applied the anesthetic, gently squeezing the site with his thumb and forefinger. Why, I wasn't sure. Was it a dosing thing? Was he just numbing the wound even more before the scary stitching began? With each visit, he engaged Julia to learn something new about her. For instance, she loves to draw.

And, she loves snacks. On my way back from the cafe with treats, Krauss stopped me in the hall and said something like, "I'm going to stitch her up; it really won't be bad." I rolled my eyes. But, he added, "I need you to work with me. I'm going to give you a task." Fine, I said, though the whole thing sounded a little gimmicky.

Krauss returned with an oversized 101 Dalmations coloring book and a handful of Magic Markers. He opened to a page overflowing with dog outlines. "Julia," he said. "I want you to color each dog's ear a different color, OK? Which color do you want to start with?"

When Dr. Jeffery Ward, a cancer specialist, and his partners sold their private practice to the Swedish Medical Center in Seattle, the hospital built them a new office suite 50 yards from the old place. The practice was bigger, but Dr. Ward saw the same patients and provided chemotherapy just like before. On the surface, nothing had changed but the setting.

But there was one big difference. Treatments suddenly cost more, with higher co-payments for patients and higher bills for insurers. Because of quirks in the payment system, patients and their insurers pay hospitals and their doctors about twice what they pay independent oncologists for administering cancer treatments.

There also was a hidden difference — the money made from the drugs themselves. Cancer patients and their insurers buy chemotherapy drugs from their medical providers. Swedish Medical Center, like many other others, participates in a federal program that lets it purchase these drugs for about half what private practice doctors pay, greatly increasing profits.

Oncologists like Dr. Ward say the reason they are being forced to sell or close their practices is because insurers have severely reduced payments to them and because the drugs they buy and sell to patients are now so expensive. Payments had gotten so low, Dr. Ward said, that they only way he and his partners could have stayed independent was to work for free. When he sold his practice, Dr. Ward said, "The hospital was a refuge, not the culprit."

As detailed by Vox's Julia Belluz, we have a reasonably clear picture of what our most likely causes of death were back in 1900, as compared to what they were in 2010. And, as you might expect, age appears to be playing a big role — conditions that worsen over time and most commonly afflict older people, like cancers, heart disease and Alzheimer's, have risen to greater prominence as our lifespans have stretched out.

Nowadays, while still deadly — especially for the very young, very old, or those with weakened immune systems — pneumonia has been relegated to the back of the list, distantly behind the top two killers, heart disease and cancer.

Making the right medical choices is harder than ever. Whether we're deciding to take a cholesterol drug or choosing a cancer treatment, we are overwhelmed by information from all sides: our doctors' recommendations, dissenting expert opinions, confusing statistics, conflicting media reports, the advice of friends, claims on the Internet, and a never ending stream of drug company ads. Your Medical Mind shows us how to chart a clear path through this sea of confusion. Drs. Groopman and Hartzband reveal that each of us has a set of deeply rooted beliefs whose profound influence we may not realize when we make medical decisions. How much trust we place in authority figures, in statistics or in other patients' stories, in science and technology or in natural healing, whether we seek the most or the least treatment - all are key factors that shape our choices. Recognizing our preferences and the external factors that might lead our thinking astray can make a dramatic, even life-saving, difference in our medical decision-making. When conflicting information pulls us back and forth between options, when we feel pressured by doctors or loved ones to make a particular choice, or when we have no previous experience to guide us through a crisis, Your Medical Mind will prove an essential companion. The authors interviewed scores of patients who have struggled with situations such as these. They also drew on research and insights from doctors, psychologists, economists, and other experts to help reveal the array of forces that can aid or impede our thinking. They show us the subtle strategies drug advertisers use to influence our choices: they unveil the extreme—sometimes dangerously misleading—power of both narratives and statistics. And they help us understand how to improve upon a universal human shortcoming — assessing the future impact of the decisions we make now. Jerome Groopman, a New Yorker writer and bestselling author, is an oncologist who guides his patients through life-or-death decisions. Pamela Hartzband is a noted endocrinologist and educator at Harvard Medical School who helps patients make critical decisions about their long-term health. As patients, the authors have very different preferences, yet they are united when conveying the book's groundbreaking message: we can cut through the confusion and arrive at decisions that serve us best.

Sunday, November 16, 2014

As there is with anything in this life, there are some upsides and some downsides to the Internet-as-doctor approach.

The downsides—as anyone who's ever Googled "sore throat" and emerged several hours later from the virtual rabbit hole convinced of their imminent death can attest—are fairly clear; a simple search can quickly become an experience that haunts the dreams of many a hypochondriac.

Even so, plenty of people regularly turn to the World Wide Web as a first-line medical resource. As Julie Beck has previously noted on this site, 72 percent of Americans have looked online for health information sometime in the past year, while one in three Americans has self-diagnosed a health problem with the help of the Internet. And doctors are following in their patients' footsteps, too: A full 50 percent of physicians turn to Wikipedia for health information, and some are active editors of the site as well.

Doctors are under the microscope. They're scrutinized for their role in our high health-care costs and graded on the quality of their care. Because of cuts in what insurance pays them, their incomes have not kept pace with inflation, creating pressure for practitioners to see more patients. Medical students, burdened by gigantic school debts, are migrating toward the highest-earning specialties and away from lower-paid primary-care fields, where doctors are in short supply.

Educators worry that physicians' stressful training — focused on technology, information and time management — might stunt their ability to gauge patients' emotions and inhibit them from discussing difficult subjects, such as a patient's wishes at the end of life. Most of the beginning medical school students whom I teach are altruistic and caring, but they wonder whether medical school and residency will grind the empathy out of them.

In three remarkable new books, physician-authors illuminate aspects of medicine that members of the profession are often reluctant to talk about: the deeply flawed care of the old and the dying, how greed influences doctors' clinical decisions, and a trainee's searing encounters with patients who are beyond his medical help.

Saturday, November 15, 2014

In the fall of 1999, a young chemical engineer named Todd Zion left his job at Eastman Kodak to enroll in the Ph.D. program at the Massachusetts Institute of Technology. While looking for a subject to research, Zion noticed a grant proposal, never funded, that another graduate student had written on the subject of drug delivery. One possibility mentioned in the proposal was the development of a kind of insulin that would automatically respond to changes in blood-sugar levels, becoming active only when needed to maintain healthy levels around the clock. If it worked, the sugar-sensitive version could transform the lives of the six million people with diabetes in the United States who use insulin. No longer would they have to test their blood-sugar levels multiple times per day and try to calculate how much insulin to take. The self-regulating insulin would curtail high sugar levels, which raise the risk of long-term complications, and eradicate, or at least reduce, the most dangerous short-term complication: hypoglycemia, when sugar levels fall so low that they can cause confusion, unconsciousness, seizures and even death.

Monday, November 10, 2014

MANY readers were shocked by my recent article about Peter Drier, who received a surprise bill of $117,000 from an out-of-network assistant surgeon who helped out during his back operation. But almost as surprising was how difficult it was during my reporting for Mr. Drier to extract his own records from the hospital.

He wanted a copy because he enjoys adventurous travel and he needed a record of the surgery in case of injury; I wanted to see the chart to make sure nothing unusual had occurred in the operating room that might justify the enormous bill. Hospitals are computerized, and patients have a right to their own records, so I assumed getting the chart would be easy.

I was wrong. The six-week ordeal included requests that needed to be made via regular mail, numerous phone calls, consent forms and an estimate for copying fees that totaled $100. This was topped off by an actual visit to the hospital by Mr. Drier, who sat in an office until he had paper documents in hand.

In a digital age when we can transfer money to purchase a house online or view a college transcript by logging on to a secure website, why is it so often difficult for patients to gain access to their medical data? And who controls our health information?

Saturday, November 1, 2014

In the fall of 2003, Elizabeth Holmes, a 19-year-old sophomore at Stanford, plopped herself down in the office of her chemical engineering professor, Channing Robertson, and said, "Let's start a company."

Robertson, who had seen thousands of undergraduates over his 33-year teaching career, had known Holmes just more than a year. "I knew she was different," Robertson told me in an interview. "The novelty of how she would view a complex technical problem–it was unique in my experience."

Holmes had then just spent the summer working in a lab at the Genome Institute in Singapore, a post she had been able to fill thanks to having learned Mandarin in her spare hours as a Houston teenager. Upon returning to Palo Alto, she showed Robertson a patent application she had just written. As a freshman, Holmes had taken Robertson's seminar on advanced drug-delivery devices–things like patches, pills, and even a contact-lens-like film that secreted glaucoma medication–but now she had invented one the likes of which Robertson had never conceived. It was a wearable patch that, in addition to administering a drug, would monitor variables in the patient's blood to see if the therapy was having the desired effect, and adjust the dosage accordingly.

"I remember her saying, 'And we could put a cellphone chip on it, and it could telemeter out to the doctor or the patient what was going on,' " Robertson recounts. "And I kind of kicked myself. I'd consulted in this area for 30 years, but I'd never said, here we make all these gizmos that measure, and all these systems that deliver, but I never brought the two together."

Thursday, October 30, 2014

Prescription drug overdoses, a dangerous side effect of the nation's embrace of narcotic painkillers, are a "substantial" burden on hospitals and the economy, according to a new study of emergency room visits.

Overdoses involving prescription painkillers have become a leading cause of injury deaths in the U.S. and a closely watched barometer of an evolving healthcare crisis. Little was known, however, about the nature of overdoses treated in the nation's emergency rooms.

A new analysis of 2010 data from hospitals nationwide found that prescription painkillers, known as opioids, were involved in 68% of opioid-related overdoses treated in emergency rooms. Hospital care for those overdose victims cost an estimated $1.4 billion.

Tuesday, October 28, 2014

If you live with breast cancer, love someone with breast cancer or worry about your risk for breast cancer, you are part of a global community of women and men whose lives have been touched by the disease. We asked our readers to share insights from their experiences with breast cancer. Browse their stories to find people like you and join the conversation.

Sunday, October 26, 2014

The 62-year-old engineer struggled as he put on his pants. His left arm, which had hurt for the last couple of days, now felt weak, and his left hand hung limp and useless, as if it were somehow paralyzed. When he went to brush his teeth, he noticed that the foamy toothpaste was pouring from his mouth. He glanced up at the mirror and was startled to see that his face was lopsided. The right side, from shaggy brow to toothpaste-covered lip, was lower than the left. The eyelid sagged, revealing the pink inner lid, and that side of his mouth was immobile.

Was this a stroke? He didn't think so. But his wife wanted to take him straight to the emergency room. He considered the option but decided against it. He had a follow-up appointment that morning with Dr. Isaac Moss, an orthopedic surgeon who was treating him for the arm pain. He figured that seeing a doctor who knew him might be better than going to the E.R. So late that morning he went to Moss's office at the University of Connecticut Health Center in Farmington.

Sunday, October 19, 2014

A FEW weeks ago, I received an email from the Danish psychiatrist Per Bech that had an unexpected attachment: a story about a patient. I have been writing a book about antidepressants — how well they work and how we know. Dr. Bech is an innovator in clinical psychometrics, the science of measuring change in conditions like depression. Generally, he forwards material about statistics.

Now he had shared a recently published case vignette. It concerned a man hospitalized at age 30 in 1954 for what today we call severe panic attacks. The treatment, which included "narcoanalysis" (interviewing aided by a "truth serum"), afforded no relief. On discharge, the man turned to alcohol. Later, when sober again, he endured increasing phobias, depression and social isolation.

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Four decades later, in 1995, suicidal thoughts brought this anxious man back into the psychiatric system, at age 70. For the first time, he was put on an antidepressant, Zoloft. Six weeks out, both the panic attacks and the depression were gone. He resumed work, entered into a social life and remained well for the next 19 years — until his death.

If the narrative was striking, so was its inclusion in a medical journal. In the past 20 years, clinical vignettes have lost their standing. For a variety of reasons, including a heightened awareness of medical error and a focus on cost cutting, we have entered an era in which a narrow, demanding version of evidence-based medicine prevails. As a writer who likes to tell stories, I've been made painfully aware of the shift. The inclusion of a single anecdote in a research overview can lead to a reprimand, for reliance on storytelling.

My own view is that we need storytelling in medicine, need it for any number of reasons.

Antidepressant use among Americans is skyrocketing. Adults in the U.S. consumed four times more antidepressants in the late 2000s than they did in the early 1990s. As the third most frequently taken medication in the U.S., researchers estimate that 8 to 10 percent of the population is taking an antidepressant. But this spike does not necessarily signify a depression epidemic. Through the early 2000s pharmaceutical companies were aggressively testing selective serotonin reuptake inhibitors (SSRIs), the dominant class of depression drug, for a variety of disorders—the timeline below shows the rapid expansion of FDA-approved uses.

As the drugs' patents expired, companies stopped funding studies for official approval. Yet doctors have continued to prescribe them for more ailments. One motivating factor is that SSRIs are a fairly safe option for altering brain chemistry. Because we know so little about mental illness, many clinicians reason, we might as well try the pills already on the shelf.

Common Off-Label UsesDoctors commonly use antidepressants to treat many maladies they are not approved for. In fact, studies show that between 25 and 60 percent of prescribed antidepressants are actually used to treat nonpsychological conditions. The most common and well-supported off-label uses of SSRIs include:

Abuse and dependence

ADHD (in children and adolescents)

Anxiety disorders

Autism (in children)

Bipolar disorder

Eating disorders

Fibromyalgia

Neuropathic pain

Obsessive-compulsive disorder

Premenstrual dysphoric disorder

Investigational UsesSSRIs have shown promise in clinical trials for many more disorders, and some doctors report using them successfully to treat these ailments:

Thursday, October 16, 2014

As health officials scramble to explain how two nurses in Dallas became infected with Ebola, psychologists are increasingly concerned about another kind of contagion, whose symptoms range from heightened anxiety to avoidance of public places to full-blown hysteria.

So far, emergency rooms have not been overwhelmed with people afraid that they have caught the Ebola virus, and no one is hiding in the basement and hoarding food. But there is little doubt that the events of the past week have left the public increasingly worried, particularly the admission by Dr. Thomas R. Frieden, director of the Centers for Disease Control and Prevention, that the initial response to the first Ebola case diagnosed in the United States was inadequate.

Wednesday, October 15, 2014

The Internet can be a dangerous place to get medical advice. Stomachaches turn into cancer, stress becomes an endocrine tumor. Crack remedies and strange diets abound. Now Google is playing with a new technology that it hopes will help people find more reliable medical information. It's called a doctor.

Google's "Helpouts" product — a service where people can search for experts and talk to them over video — is running a trial program in which people who are searching for symptoms like pink eye and the common cold can video-chat with a doctor. The company is working with medical groups including Scripps and One Medical, which are "making their doctors available and have verified their credentials," according to a spokeswoman.

"When you're searching for basic health information – from conditions like insomnia or food poisoning – our goal is provide you with the most helpful information available," the spokeswoman said in an emailed statement.

Tuesday, October 14, 2014

Will history someday show that the electronic medical record almost did the great state of Texas in?

We do not really know whether dysfunctional software contributed to last month's debacle in a Dallas emergency room, when some medical mind failed to connect the dots between an African man and a viral syndrome and sent a patient with deadly Ebola back into the community. Even scarier than that mistake, though, is the certainty that similar ones lie in wait for all of us who cope with medical information stored in digital piles grown so gigantic, unwieldy and unreadable that sometimes we wind up working with no information at all.

We are in the middle of a simmering crisis in medical data management. Like computer servers everywhere, hospital servers store great masses of trivia mixed with valuable information and gross misinformation, all cut and pasted and endlessly reiterated. Even the best software is no match for the accumulation. When we need facts, we swoop over the surface like sea gulls over landfill, peck out what we can, and flap on. There is no time to dig and, even worse, no time to do what we were trained to do — slow down, go to the source, and start from the beginning.

He was sure it was a patient of his, a woman in her 60s, who had been admitted for chest pains. His team had sent her for a CT scan.

He ran down the eighth floor hallway, then took the elevator to the second floor. It was his first code blue at Woodhull, a public hospital in Williamsburg. But in Guatemala, where he had worked at a public hospital, San Juan De Dios, as part of his medical school training, he had responded to dozens of these alarms.

"But never with the right resources," Dr. Sanchez said. "There were no monitors or defibrillators on the floor. At least half the patients died."

In radiology, his patient, an African-American woman who had just had a heart attack, was surrounded by emergency department doctors and nurses. A tall physician with braids down her back was quietly overseeing everything. A doctor touched the patient's neck and said, "It's not a code blue — she has a pulse!"

Saturday, October 11, 2014

When a helicopter rushed a 13-year-old girl showing symptoms suggestive of kidney failure to Stanford's Packard Children's Hospital, Jennifer Frankovich was the rheumatologist on call. She and a team of other doctors quickly diagnosed lupus, an autoimmune disease. But as they hurried to treat the girl, Frankovich thought that something about the patient's particular combination of lupus symptoms — kidney problems, inflamed pancreas and blood vessels — rang a bell. In the past, she'd seen lupus patients with these symptoms develop life-threatening blood clots. Her colleagues in other specialties didn't think there was cause to give the girl anti-clotting drugs, so Frankovich deferred to them. But she retained her suspicions. "I could not forget these cases," she says.

Back in her office, she found that the scientific literature had no studies on patients like this to guide her. So she did something unusual: She searched a database of all the lupus patients the hospital had seen over the previous five years, singling out those whose symptoms matched her patient's, and ran an analysis to see whether they had developed blood clots. "I did some very simple statistics and brought the data to everybody that I had met with that morning," she says. The change in attitude was striking. "It was very clear, based on the database, that she could be at an increased risk for a clot."

The girl was given the drug, and she did not develop a clot. "At the end of the day, we don't know whether it was the right decision," says Chris Longhurst, a pediatrician and the chief medical information officer at Stanford Children's Health, who is a colleague of Frankovich's. But they felt that it was the best they could do with the limited information they had.

A large, costly and time-consuming clinical trial with proper controls might someday prove Frankovich's hypothesis correct. But large, costly and time-consuming clinical trials are rarely carried out for uncommon complications of this sort. In the absence of such focused research, doctors and scientists are increasingly dipping into enormous troves of data that already exist — namely the aggregated medical records of thousands or even millions of patients to uncover patterns that might help steer care.

Thursday, October 9, 2014

To the casual observer, it seems that a new case of Ebola is diagnosed in the U.S. every day, that the disease will soon explode in a terrifying outbreak. Both of these observations happen to be false — most initial reports of Ebola have turned out to be false positives and, because of the United States' modern health infrastructure, it's exceedingly unlikely the disease will spread. But that hasn't prevented a fair amount of hysteria and misinformation from taking hold, and the very social-media tools that could help bring people accurate, panic-suppressing information about the virus are in many cases doing just the opposite.

"Ebola's the kind of disease that zombie movies are made out of," said Abdulrahman El-Sayed, a researcher at Columbia's Mailman School of Public Health. "It's the kind of thing where if you're not close to the science and don't understand the epidemiology of it, it's a very scary-sounding disease — you bleed all over the place, it kills more than 50 percent of the individuals who contract it, it's spreading like wildfire in West Africa." And given that we live in an age in which everyone is just a few keystrokes away from gruesome images of Ebola's symptoms and victims — not to mention from less-than-rigorous news sources stoking hysteria over the disease — experts face unique challenges in communicating key information about the virus to the public.

It is an inherently tricky task from a communications perspective. Ebola is, after all, a deadly and vicious disease. But the conditions that facilitated its spread in West Africa simply aren't present in the U.S., meaning its arrival here, while potentially tragic for those afflicted and their families, does not augur a larger outbreak.

Experts have actually known for a while that Ebola was going to show up in the U.S. Ever since the scope of the West African epidemic became clear, said El Sayed, American public-health officials have been hammering home the same message: "'There is gonna be an Ebola case here, but there's probably not going to be a transmission.'"

But before experts can effectively explain this, they first have to face down the biggest, scariest images of the disease lodged in the public's imagination thanks to both fictionalized accounts and sensationalistic news coverage. "You have to address everybody's worst fears before you can have a logical conversation about it," said El-Sayed.

Sandro Galea, also at Mailman, stressed that "Clear, consistent, honest communication is essential," especially now, during the early days of this outbreak's presence in the U.S., when rumors are running rampant, fueled by a lack of concrete information. "There's no question that uncertainty allows the space for misinformation to spread," said Galea, "which is why those in positions of authority need to be honest when there are things we don't know."

If officials don't get the message out effectively and misinformation and panic do spread, the results are unlikely to be rioting in the streets or toppling of the government (as opposed to the hardest-hit parts of West Africa, where Ebola really has caused varying degrees of societal upheaval), but they can still be damaging.

Galea said a primary symptom of panic over a disease is what he called "Flooding of the health-care system with the 'worried well'" — that is, folks who don't have the disease in question, but who think they do. "Something we learned from the SARS epidemic was that there were many more people who presented to emergency departments and their physicians because they were worried about having SARS than there were who actually did," he said. When these fears escalate, they can be dangerous in their own right, straining the health-care system with hypochondriacs "at a time when you want the system to be robust and able to respond to actual burdens."

There are reasons such straining is more likely to take place in 2014 than it might have been in, say, 1974. As Dietram Scheufele, a science-communications researcher at the University of Wisconsin pointed out, Americans get their health news and information in a vastly different way now than they did in the recent past.

"The big problem that agencies [like the CDC] have is that they, in most cases, can't communicate with audiences directly," he said. According to Scheufele, this was less of a problem back in the days when there were more reporters immersed in public-health and epidemiology beats, he said — and back when Americans had fewer sources of information. Today, though, he thinks there are fewer competent "middlemen" positioned between experts and mainstream audiences, and there's also a lot more social media — which is, by its nature, agnostic on the question of which information is accurate.

So yes, one can argue — as El-Sayed and Galea did — that the CDC's recent Twitter Q&A, in which it addressed some pretty scary questions, was an effective, modern way of cutting out the middleman altogether and communicating with the public directly. But Scheufele pointed out that there might be limits to this approach: "What's the Twitter following of the CDC? I'm sure it's much less than what Jenny McCarthy has, who routinely writes against vaccinations and everything else." (He's right: TheCDC has 378,000 followers, a number dwarfed by McCarthy's 1.23 million.)

It cuts both ways: People have as much access to information — including from trusted sources — as ever before, but they are also are enmeshed in networks, on Facebook and elsewhere, that might serve them heaping doses of panic rather than some much-needed perspective.

"On the one hand, the internet has democratized everything, which is excellent," said El-Sayed. "On the other hand, science is one of those places where there is a right answer. We don't always know it, but it's not a matter for public debate and conversation and opinion."

Is the government doing enough to protect us from Ebola? At a time of widespread panic and misunderstanding, it's a hot question — one that has generated a lot of conversation and at least one memorably nonsensical rant from Nancy Grace. And this week, the Centers for Disease Control announced plans to institute Ebola screening for passengers arriving in the country (as of this writing, we don't yet have details as to what this will look like).

As it turns out, this is a pretty pointless move from a public-health standpoint, but it can still tell us something interesting about how governments respond to a fearful populace.

During a segment on the screening program on yesterday's Morning Edition, reporter Anders Kelto interviewed Larry Gostin, a global health professor at Georgetown. "Let's not have the false impression that this is a tried-and-true method and it's gonna keep Ebola out of the United States — it's just not the case," said Gostin. There's little evidence such screening would actually detect Ebola patients, he explained.

It raises an obvious question: Why, then, is the government instituting this policy? Gostin's response:

[People who are scared] insist to their government, "Do something. It doesn't matter what it is — show us that you're doing something. Tell us that we have no risk." And governments, even if they know better, will sometimes respond to that political outcry. They're under a lot of pressure to do something, [to] make the public feel reassured even if it really doesn't make them safer.

Remember that Ebola just doesn't appear to be a major threat to the U.S. — none of the factors that turned it into a West African pandemic are present here. That doesn't mean people aren't freaking out, though — and understandably so given how horrific a disease this is. So how does the government respond? Um, we'll screen people at airports! Yeah! Which leads to an odd situation in which the government wins political points for taking ineffectual action against an imaginary threat.

Odd, yes, but not particularly uncommon. Think of all the 9/11 TSA reforms that people love to gripe about. Was taking off our shoes going to provide any sort of meaningful defense against the next Al Qaeda plot? Probably not (just ask the administrators at the many, many top-tier airports around the world that did not enact these measures). But even as we complained and struggled to bend over and get our footwear off, it made us feel like the authorities were responsive to our fears. At a time of great uncertainty, that was important.

The same logic applies here. As human beings, we derive a real psychological benefit from tangible evidence that the people charged with protecting us are doing a vigilant job — even when the substance of the action in question is questionable. So thank you, government, for soothing our misplaced Ebola fears in a highly visible but ultimately ineffectual way. Or something?